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HomeMy WebLinkAbout0500 OCEAN STREET (3) .'SD D Cce.a-�n S4-, bit, J 4, a Application numb e ...a BUILDINGDEPT. Fee .............................................................................. Building Inspectors Initials.... NAM ......................... s�� �,•� MAR 0 4 2020 Date Issued.:........ I`. �. TOWN OF BARNSTABLE324- Map/Parcel....v . .........V...G..11......:.. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: S NUMBER _STREET VILAGE Owner's Name: rri mA�. (� P � Phone Number Email Address: k Cell Phone Number 6 j-7 7Rq , 33q Project cost S 8 Check one Residential L-/ Commercial SCANNED OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: fw Date: 'l 2--0 LZ TYPE OF WORK E] Siding Windows (no header change)#___13 Insulation/Weatherization 0 Doors(no header.change)#" Commercial Doors require an inspector's review Q Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name ) Q Of Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# -OY W7 / (attach copy) Email of Contractor e H(f h! T r4 J 1 + 6n Phone number (),9 `77 ALL PROPERTIES THAT HAVE STRUCTURES OVER 7S YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT.YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER.........................................T.................. *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach`floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each`tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or> Yes No ,if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. , ,.J"f ; I If food is being served at your event please obtain d Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. iF9 ooAkJa *WOOD/COAL/PELLET STOVES .' Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number t I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature r Date t , 'APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. < .. . ,Y a . r 3 i t D. � i 6 < r78`f ~-:-RV§af�' - t. pi hit' 4 ua Tw Mi x r y U� Mee Fe ul %li a o 1 , r¢ y�/�'� •1 yq}9�y�g Nn is ,44 V LP.''t'yfi�i' �A' H YY a.yp tr• A`40R CERTIFICATE OF LIABILITY INSURANCE 03(04/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE THE POUCHES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME Mark Sylvia MARK SYLVIA INSURANCE AGENCY LLC PHONE (508 957-2125 FAX aC No): E-MAIDAD Lss_donna marksylviainsurance.com 404 MAIN ST INSURERS AFFORDING COVERAGE NAIC ag CENTERVILLE MA 02632 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER li STEVEN L MELLOR INSURERC.: MELLOR BUILDING&REMODELING INSURERD: P O BOX 627 wsuRER I CENTERVILLE MA 02632 INSURERF ' COVERAGES CERTIFICATE NUMBER: 511887 ` _ REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TI=E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDL CED BY PAID CLAIMS. ADDLSUBR TR TYPE OF INSURANCE POLICY NUMBER MFMIDD EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE ❑OCCUR D GE R W ED PREMISES Me occurtence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Me accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED - PROPERTY DAMAGE AUTOS• Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LUU3 CLAIMS-MADE N/A AGGREGATE $ DEC RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X STATUTE ERH ANYPROPRIETORIPARTNERIEXECL rNE E.L.EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBEREXCLUDED? NIA NIA N/A AWC40070355822019A 06/17/201E 06/17/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A 1ESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sdiedule,may be attacl red H more space is required) Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to 3mployees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. this certificate of insurance shows the policy in force on the date that this certificate was issued(unless;the expiration date on the above policy precedes the issue date of this :ertificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at Nww.mass.gov/lwdAmorkers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLkTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. THE EXP'RATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Bamstable Building Department ACCORDANCE WITH THE POUCY PROVISIONS. >.00 Main Street AUTHORIZED F EPRESENTATIVE iyannis .MA 02601 ` ( C,.C� Daniel M Cro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988 2014 ACORD CORPORATION. All rights reserved. .CORD 25(2014/01) The ACORD name and logo are reglsterec'marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name(Business/organization/Individual): bi" Address: fv'-D O cK GQ�7 City/State/Zip: CD631 Phone#: Are ou an employer?Check the appropriate box: Type of project(required): 1.9I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hived the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []'Remodeling ship and have no employees These sub-contractors have g; ❑Demolition working for me in any capacity. employees and have workers 9. ❑Building addition [No workers'comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its I . Electrical repairs or additions officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work, , �, _ 1 r myself. [No workers'comp. ' " right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 1323'bther�� _ comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who'submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation ins�r_gnce for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:I W t^ 'n j)'��� �a+0`)9 3� Expiration Date: Job Site Address: 1477 �L `� City/State/Zip: - Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sip,nature• Date: Phone'-#--. - Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Autbority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Its Information `and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers.'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number: In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 W 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia t ' ✓� (�Mp�7 e272LLEO.Cl2 O�✓//IJGLd41G�G/���G1E�y _.. .. . Office of Consumer Affairs&Business Regulation ` HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only {i TYPE{Individual before the expiration date. If found return to: , Expiration Office of Consumer Affairs and Business Regulation ,11/02/2020 1000 Washington Street-Suite 710 STEVEN L ME L1r _ ry iF;t` Boston,MA 02118 STEVEN L.MELiiF' 74 FROST LN HYANNIS.MA 02601 ' Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr4,6 tA spyrvisor CS-049879 [Pires: 05/22/2020 �.. r STEVEN L.M&LOR �- P.O.BOX 627�� CENTERVILLE IIR� 026 Commissioner CZ ' TOWN OF BARNSTABLE BUILDING PERMIT,APPLICATION .t , y Map Parcel 'Application # Health Division Date Issued 69 Conservation Division ` Application Fee Planning,Dept: Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH =Preservation / Hyannis Project Street Address co 0 04A . S"r tit.S M 7' Village Owner Address — Telephone Permit Request Square feet: 1 st floor: existing proposed �2nd floor: existing proposed Total new Zoning District' Flood Plain Groundwater.Overlay s roject Valuation Construction Type Lot Size Grandfathered: 0 Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family .Q Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) . Number of Baths: Full: existing new Half: existing new.- Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor F80om Count { Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Othery Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/ oal stove, ❑Yes 0'No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑e ting ❑ new size_ Attached garage: ❑existing 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current-Use— - Proposed Use A�PJPL�ICANT INFORMATIONILDER j �' 17C..�p- W`S i(B�l'7S ��MEOWNER) Name ��C Telephone Number Address _ ��� License# Home Improvement Contractor# l61r�90S Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER F 4 DATE OF INSPECTION: FOUNDATION 't FRAME INSULATION FIREPLACE ` ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston, MA 02111 a t� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ��,, ���� Please Print Legibly ((���JW Name(Business/Organization/Individual): R 7o-f qvz. v Address: ' City/State/Zip: r -7W lQ tWJ Mk C hone,-#: 7P — /P I / Are 'on an employer? Check the appropriate box: Type of project(required): L am a er with Y emP.to 4. 1 am a general contractor and 1 � 6. 0 New construction employees (full and/or part-tiine).* have hired the sub-contractors 2.0 I am a sole proprietor or'partner- listed on the attached sheet. 7.. Remodeling ship and have no employees These sub-contractors have g. '0 Demolition working for me in any capacity. employees and have workers'comp. 0 Building addition [No workers'•comp.-insurance comp. insurance.# required.] S. [] We are a corporation and its "10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions. myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp,insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: J(X.> G`;A ' iSi/ 14"l j"J t S City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sign.atur . - Date: �/ o — Phone# ®& �7� j Official use.only. Do not write in this area,to be completed by city or town officiaL .City or Town: Permit/License# Issuing Authority(circle one): I.Board of health '2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: f Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-conkactor(s)name(s), address(es)and.phone number(s) along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must.submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Please do not hesitate to give us a call. The Department's address,telephone-and fax number: .The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigatians. 600 Washington Street Boston, MA 02111 TO. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax# 617-727-7749 www.mass..gov/dia j �YHE T � Town of Barnstable Regulatory Services " sa MAS& Thomas F. Geiler,Director Mass. Et6 o�►`�� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I _ dt"711114 , as Owner of the subject ro e P P rtY hereby authorize CRCIUJ►J [Jr to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) /�� AJ*I S S�p�90 Signature of Owner Date Print Name If Property Owner is applying for permit please complete the . Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION c Town of Barnstable o Regulatory Services ` Thomas F.Geiler,Director + BAmsrABLE, " MA99. 9q,A 1e39. rti � Building Division rfn Ml*y Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFIMTION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns, You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC � I oard Ponstructlo g Regulasor;tions and Standardus nISup erviLicense• Licenj"se 69514 al •� � Ex�iratl n - 'I f ° a tTj /2010 Tr# 1fi78t i �strl.tlorl _Q0 t 2 J( ` Y STEPHEN P LEBL 83 N ��� `i F3 r Tr3 i ce5 ORTH f MIDDLEI3QGROVE � � J 4 _ 4 : i`#. �; Comrriissione'r' ✓lie Zoorynmzaouoea//a o/,_/l/faaaacc<`iugeCta JJ Board of Building Regulations and:Standards " License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR ' before the expiration date. If found return to: .:4 '. R egistratiori:: 162825 Board of Building Regulations and Standards Expiraton 4/13/2011 Tr# 282990 One Ashburton Place Rm 1301 Boston,Ma.02108 Type LLC CROWN KITCHENS STEVEN LEBLANCE�IIt°u 90 KALMAN PL. �� f/ TAUNTON, MA 02780 Administrator valid Without simature a To: TOYS OF BAt:YSTABIE From: Awe Chandler 6-02-19 5:07an p. 2 of 2 ��® CERTIFICATE OF LIABILITY INSURANCE OATEPOAMOITYY 1 °R00"' ATLANTIC ADVISERS INSURANCE AGENCY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BOX t�57 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO NO BOX 8 MA 02061 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (781)6594040 INSURERS AFFORDING COVERAGE NAIL E INSIIF�D CROWN KITCHEN 81 BATHS LLC INSIMRw LIBEM MUTUAL GROU 80 KALMAN PLACE INSURERS: TAUNTON MA02780 INISdIRER C: WASURER O: DISzIItERE: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OESCRIBED HERUN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAVAS_ a POLICY 141MBER VOUCT EFFECTIIB POLICY E tPIRAtOM y1pi8 GENERALLIABGIIY EACH OCCURRENCE { COMMERCIAL GENERAL UAKITY PREM SES aancD i CLAMMACE F-1 OCCUR MED EXP ore 6 PERSONALAADV WAXiY { OENEI►AL AGGREGATE i GENL AGGREGATE t GOI APPLIES PER: PRODl1CTS-COMPIOA AGG { POLICYPRa LOC AUTOMOBG E LIA811.11Y COLUMEO SINGLE LIMIT ANY AUTO ALL OWNED AUTOS 8004Y ELItAtY { SCH£DULEDAUTOS (Pa081t0�) 14011120 AUTOS BODILY 94AMT NON-O'A'NEDAUTOS (� { PROPERTYDANIAMs GARAGELIABL.ITI AUTO ONLY-EAACCIGENT { ANY AUTO OTHER THAN EA ACC { AUTO ONLY: AG. { EXCESSIUMBRELLALIIIBMTt EACH OCCURRENCE { GCCILR ❑CLAIMS MADE AGGREGATE { F s ]CEOUCTMLE { RETENTION! { { A "ORAERSCON"ASATION WC2-31S-37206"19 3/14/2= 3/14MIO �/ I wcSTATtI� mN- AND E10 LOTERS'LIABILITr ANY PROPRIETORIPARTNEIMXECUTIVE YIN E.LEACIIACCMENI { to fo OFFICER IMBEItEXCLUDED? ❑Y (N��tvR ro��,m V IL NN) E.L.DISEASE-EA EMPLOYE i 100000 =20 PROVISIONS below C.L.DISEASE•POLICY LIST 16 500000 OTHER OESICNPTION OF OPERATIONS I LOCATIONSI•YENtCLES I EXCLUSIONS AVOW BY EM30FAEWAT I SFECML PROVISIONS The Workers'compensation policy provides Coverage only for the state of MA as Voted in section 3A of the policy. CERTIFICATE HOLDER CANCELLATION IIIW WANYOFTNMAOOYEDUCRMCPOLICOSSECAMMU0BEFORETIEEMPATWN TOWN OF BARNSTABLE GATT:THERECIF.111M 1IMMI11MAMMILOMEAVORTOOM 7 DAYS TYRITTEN 200 MAIN STREET NOTICE TOMM CERTIRCATE HOLOER NAMED TOTHE LE/T,BUT PAUlRE TO W SOSHAL L HYANNIS MA 02601 QVOSE 60 O51M=RN OR UASWW OF ANY WO UPOIN THE INSIRML ITS AUNTS ON R�REBENtATIVES. AUTNORI�®REPAE3E111ATIVE eII Etdialgll ACORD 25(200S104) 1 ACOR-0 CI_ POFCATl . All Tlpiss msorvad. CYST'-. - SOFSIS3 CLEWF CCM— 117-CS-0 Anne Mandter 61212;0 5:tl:ee M Fer.3 e2 I The Yachtsman 500 Ocean Street, Hyannis, MA 02601 Yachtsman Condominium Trust P.O. Box 1283 Hyannis, MA 02601-1283 (508)775-1515 el f r 14 � �� y Hs � � s } 7\� Vr^ {I a ---------- REF